Synopsis

The Grand Jury investigated
the need for Automated External Defibrillators (AEDs) in Santa Cruz
County, how they are currently being
deployed, and what policies are in place for their use in saving the lives of
sudden cardiac arrest(SCA) victims.

An estimated 325,000 lives are lost
each year in the United States due to sudden
cardiac
arrest.[1]From
October 2004 through September 2006, 484 people were victims of sudden cardiac arrest in Santa
Cruz County alone.[2]
With the recent advances in technology, the modern
AED units are simple and relatively low cost. Many lives
could be saved if they were made available and used within the
first few minutes after the onset of sudden cardiac arrest.
Although fire and ambulance
services in the county are
well equipped and have an excellent reputation for effective medical response,
their ability to reach a patient who is suffering from sudden
cardiac arrestin time is highly problematic. The
solution lies with AEDs being more widely distributed at key
sites throughout the county.

In providing what is fast
becoming a “standard of care,” the
county
must keep uptodate with
technology, national trends and the legal liability associated with failure to
be proactive. The county should re-examine
its policy and its requirements for the placement of AEDs as recommended in this
report.

Definitions

AEDAutomated External Defibrillator — a computerized
medical device that automates
the process of administering an electrical shock to the
heart to restore its natural rhythm.

Advanced Life Support (ALS)Medical care provided by emergency
medical technicians trained to assess a patient's condition,
administer drugs, defibrillate and provide advanced airway management prior to
transportation to the hospital.

AMRAmerican Medical
Response — a private ambulance
service that coordinates with emergency services agencies
in the county for first responder Advanced
Life Support service.
AMR is the sole provider of medical transport in the county.

Basic Life Support (BLS)Basic
Life Support consists of a number of life-saving techniques focused on the ‘ABCs’ of pre-hospital
emergency care: Airway, Breathing and Circulation.BLS
generally does not include the use of drugs or invasive skills, but
with advances inAEDs may now include
defibrillation.

CPR
Cardio-Pulmonary Resuscitation.

EMSIA
Emergency Medical Services Integration Authority — a
combination of county fire districts and departments that work
together with American Medical Response to
provide Advanced Life Support medical services in Santa Cruz County.

PADPublic Access Defibrillator — an AED that isavailable
in public and/or private places where large numbers of people gather or people
who are at high risk for heart attacks live.

Standard of CareThe level of service that
the average, prudent provider in a given community would practice.

VF/VTVentricular Fibrillation/Ventricular Tachycardia — chaotic heartrhythms
that can be restored to a natural spontaneous rhythm through
defibrillation.

Background

Heart disease is a serious
public health issue. In the United States, at least 61 million
people have cardiovascular disease, resulting in an estimated 1 million
deaths per year. About one-third of these deaths, 300,000 to 400,000, are due
to sudden cardiac arrest, the sudden and unexpected loss of heart function.[3]

Most often,suddencardiac
arrest is due to chaotic beating of the large chambers of the heart, called
ventricular fibrillation.Typically, its victims
have no warning and quickly collapse and lose consciousness.
The only treatment that can save their lives is the quick use of a
defibrillator, a medical device that administers an electrical shock to the
heart to restore its synchronous pumping rhythm. Defibrillators work by giving
the heart a controlled electric shock that has the chance to resynchronize the
contraction of the heart muscle and restore its normal rhythm.

The overall survival
rate for out-of-hospital cardiac arrest is 6.4 percent nationally and
6 percent in Santa Cruz County.[4]Immediate
treatment with defibrillationcan improve
the odds of survival significantly — resulting in greater
than 90 percent survival. Every minute of delay decreases the survival
rates by 10 percent; after 10 minutes without
defibrillation, it is highly unlikely that asudden
cardiac arrest victimwill survive.

Defibrillators are available in
two forms, manual and automated. Only trained medical professionals are
qualified to use manual defibrillators. Manual defibrillators require
interpretation of the patient’s condition and an understanding of the
capabilities of the defibrillator to deliver an effective and safe shock.

Recently, as a result of
technological advances and the development of special computer applications, a
new kind of defibrillator has become available. Today’s AED uses
embedded computer chips and sophisticated programming to
analyze heart rhythms quickly and accurately and determine if a shock should be
given. It will only deliver
a shock if the readings indicate that one is necessary. This automation
makes it possible for non-medically trained individuals to deliver
the same life-saving treatment as medical professionals without
risking an accidental or inappropriate shock. Most modern AEDs are
equipped with synthesized voice instructions telling the
user how to proceed in the case of a cardiac emergency. This new equipmentis very
easy to use. In fact, in one study,
untrained sixth graders took only 30 seconds longer than trained
emergency service technicians to prepare a patient for a shock.[5]

Another advantage of modern
automated defibrillators is the fact that, like most
electronic equipment, they have becomemore
affordable and available to the general public. In the past, their
cost put them out of the reach of most people, but today
they can be purchased through retail and online outlets for prices ranging from
about $1,000 to $2,000.

The American Heart Association
has recognized four critical factors associated with improved survival rates
from sudden
cardiac arrest in communities. More
people survive when this sequence of events, called the Chain of Survival,
happens as quickly as possible. These four steps are:

Early Access — recognizing that a cardiovascular
emergency exists and immediately notifying the Emergency Medical Services
(EMS) system, usually by calling 911.

Early CPR — starting CPR immediately after cardiac
arrest to circulate blood to vital organs buys time for the victim until
defibrillation can be administered.

Early Defibrillation — defibrillation of the victim
as soon as equipment arrives.

Establishing a viable chain
of survival
in a community requires an integrated plan that relies on the cooperation of
local government agencies and ordinary citizens to know what to do and be
prepared to take action when an emergency occurs.

Findings

Status
of Emergency Services in Santa Cruz County

1.The
911 system for most of Santa Cruz County is administered through the Santa Cruz
Consolidated Emergency Communications Center, commonly called Net Com.
Additional public safety answering points for the 911 system are in Scotts
Valley and at the University of California’s Santa Cruz campus.

2.Net
Com is an up-to-date, modern
facility. Dispatchers have access to computer-aided
dispatch systems that allow them to rapidly send
police, fire, and medical assistance when needed.For medical
calls involving a person not breathing, such as sudden cardiac arrest,
Net Com was able to dispatch Emergency Medical
Service units within 60 seconds 92 percent of the time in 2006.

4.The
remainder of the county receives first responder Basic Life Support medical
services from a variety of smaller fire departments and the California
Department of Forestry.

5.American
Medical Response (AMR), a private ambulance service, coordinates with the EMSIA
agencies for first responder ALS service and through its contract with the
County of Santa Cruz is the sole provider of medical transport in the county.

6.EMSIA
fire agencies are able to provide a paramedic to a medical emergency within
eight minutes of dispatch 90 percent of the time in urban
areas.

7.AMR
is able to provide an ambulance to a medical emergency within 12 minutes of
dispatch 90 percent of the time.

A fire
department paramedic is the first one to arrive at a medical emergency
about 60 percent of the time.

The expectations of service are
carefully listed in the emergency services’ contracts
issued by the county to American Medical Response. AMR
coordinates its services with the EMSIA to ensure the best possible
service to the citizens of Santa Cruz County.

AED Distribution and Training

10.Manual defibrillators, such as those carried
by fire department and AMR paramedics, are expensive and complex
and require significant training and experience to be effective.
Conversely, automated external defibrillators
(AEDs) are reasonably priced and simple to operateby
anyone with a minimum of training.

11.Santa Cruz
County does not have a comprehensive policy regarding
the distribution and installation of AEDs in public locations.

12.AEDs are
carried in police patrol cars in Scotts Valley. No other law enforcement agenciesin
the county require AEDs in their vehicles.

13.The
locations of AEDs in the county are not available to Net Com dispatchers.

14.When
AEDs are deployed in public buildings, they are often not visible and therefore
not accessible when needed.

15.CPR
classes, including training in the use of AEDs, are available through a variety
of sources in the county.

Need
for AEDs

16.While
immediate CPR can buy valuable time for a sudden cardiac
arrest victim, defibrillation is the only treatment that can save the victim’s life
by restoring the heart’s spontaneous rhythm.

17.People of
any age may suffer sudden cardiac arrest and die
suddenly.

18.Sudden
cardiac arrest is different from a heart attack although coronary
artery disease may reduce heart circulation and eventually result in SCA.

19.Often the
first sign that a person is vulnerable to ventricular fibrillation is an attack
that results in sudden cardiac arrest and death.

20.In Santa
Cruz County, approximately 250 people per year
are victims of out-of-hospital sudden cardiac arrest. From
October 2004 through September 2006, more than half of these victims (51 percent) were not
candidates for resuscitation, mostly because too much
time had elapsed before emergency medical services could be activated.[6]

21.Some common
causes for sudden cardiac arrest include
asphyxia due to drowning or other oxygen deprivation, congenital heart
conditions, sudden blows to the chest, electrocution, and coronary artery
disease.

22.The worst
combinationfor
cardiac arrest survival is if patients collapse without witnesses, and when
discovered, receive no bystander CPR while emergency services personnel are enroute.
In a two-year period in Santa Cruz County, only two of 215 patients in this
situation had their hearts begin to beat again, and
neither survived. When sudden cardiac arrest was
witnessed and immediate CPR was administered, nearly a
quarter of the victims regained pulses and 10 percent survived. The
survival rate jumped to 19 percent when EMS professionals witnessed cardiac
arrest and could begin treatment
immediately.There were 16 EMS-witnessed
cases in the two-year period, and three of those were found
to be in ventricular fibrillation (as opposed to those with no electrical
activity or pulse). All three were successfully resuscitated with defibrillation
only.[7]

23.Some
experts believe that a connection may exist between the use of ‘Tasers’
by law enforcement and sudden cardiac arrest in some
individuals.

24.To
improve the survival rate of victims of out-of-hospital cardiac arrest in Santa
Cruz County, the
Emergency Medical Services Integration Authority recommends “promulgating
citizen CPR programs, Public Access Defibrillator (PAD) programs, and
continued rapid EMS response using all the latest AHA (American
Heart Association) recommendations for CPR, defibrillation, and
advanced life support care.”[8]

Laws
related to AEDs

25.Effective
July 1, 2007, the State of California will require all health clubs
to be equipped with AEDs on site and establish a
program of training, maintenance, and record keeping.

26.Good
Samaritan laws protect most citizens from liability if they take action in a
medical emergency, which includes using an AED. Conversely, lawsuits have been filed
against organizations such as amusement parks and airline companies for not
having AEDs readily available.

27.AEDs are
now required at FAA governed airports and on all commercial airliners.

Conclusions:

1.In
Santa Cruz County, the American Heart Association’s recommended
‘Chain of Survival’ for victims of sudden cardiac arrest is incomplete.
Specifically, the availability of early CPR and early defibrillation is
lacking.

Although Net Com and the Emergency Medical
Services Integration Authority cooperate to ensure
advanced
life support (ALS) services are sent to medical emergencies
as quickly as possible, even the most rapid dispatch and transit times by
Net Com and ALS providers will rarely get a defibrillator to the victim
within the three- to five-minute window recommended by the American
Heart Associatjon for best survival, especially in outlying
areas of the county.

Modern AEDs are simple to use and can improve the
chances of surviving sudden cardiac arrest if they are
deployed in the community and if there is a base population of trained
citizens able to step in when a medical emergency requiring the use of an
AED occurs.

When AEDs are deployed in the community, they need
to be made visible and readily accessible to the public so they can be
used immediately.

Net Com staff could improve response time in cases
of sudden cardiac arrest if they
knew the locations of nearby AEDs.

Deaths due to sudden cardiac arrest can
be reduced through a combined program of public education in
CPR and effective public access
defibrillator (PAD)
implementation.

The availability of an AED is becoming the expected
‘standard of care’ in many situations.

The availability of AEDs
in county buildings—
and their deployment in sudden cardiac arrest incidents — may
protect
the county from possible litigation and
financial liability.

Providers of AEDs may be protected from liability
if they comply with simple regulations regarding training, maintenance,
record keeping, and medical oversight.

Recommendations

The Santa Cruz County Health
Services Agency should establish a public education program to enhance the
community’s knowledge and awareness of CPR and
the use of AEDs as a life-saving measure.

The locations of AEDs in the county should be
entered in Net Com’s Computer-Assisted Dispatch
system.

Santa CruzCounty
should require AEDs in county buildings
with more than 100 employees or daily visitors and
in county detention facilities, including
Juvenile Hall.

Santa Cruz County should encourage the use of
AEDs in the following public
locales and private settings:

§·Public schools

§·Public swimming pools

§·Public libraries

§·Large concerts and other public
events

§·Public golf courses

§·Churches with a capacity of 100 or
more

§·Private schools

§·Private recreation clubs

§·Medium to large hotels and motels

§·Shopping centers

§·Medical and dental offices

§·Private golf courses

·Senior citizen centers and care facilities

The county and each city should equip
law enforcement vehicles with AEDs.

The county should establish a
mechanism to ensure that once AEDs are
deployed by public agencies, those
responsible meet the requirements needed to
shield the county from liability by providing training, maintenance,
record keeping and medical oversight.

The county should establish a
reporting and inspection mechanism to ensure
that AEDs deployed in the community are identified by Net Com
and therebyviable
in case of an emergency.

The county should develop a strategy
for implementing a meaningful public access defibrillator program that
meets the criteria of the American Heart Association and American Red
Cross recommendations.

The county should explore funding opportunities to
pay for an expanded public access defibrillator program
from both public and private sources, possibly enlisting the aid of
community service organizations.

Commendation

Santa Cruz County’s emergency
services teams and organizations for providing the most efficient and
responsive services possible under current conditions.